Ramblings of an Emergency Physician in Texas

…in their efforts to harm themselves. I’ll never forget the patient we had to admit serially because he had an alcohol problem so the family wouldn’t buy him booze. They would, however, buy him Listerine, which he’d drink for the alcohol but then vomit for hours, probably from the other ingredients.

In the second case, a 43-year-old man with alcoholism was treated for mysterious chest pains and other symptoms.

“Before those results were obtained, the patient was seen in the bathroom drinking the alcohol-based hand wash from its dispenser,” Dr. Ashkan Emadi and Dr. LeAnn Coberly of the University of Cincinnati wrote.

“When asked why he ingested the hand cleaner, he pointed to the label, which read, ‘Active ingredient 63 percent v/v isopropyl alcohol.’ He explained that this percentage is higher than that in vodka,” they added.

Heh.

Oh, and this’ll never fly, and for good reason:

It takes only a small amount of isopropanol to kill, by depressing the heart and central nervous system, they wrote.

They suggested that makers of the hand gels change the labeling.

Update: I mean that if they meant to exclude the contents that’d be wrong, but if they want to put “Do Not Drink” on the label that a) won’t keep anyone from intentionally drinking it, and b) would be more for the lawyers than the public.

Death from ingestion of isopropanol is uncommon. Isopropanol has 2-3 times the potency of ethanol and causes hypotension and CNS and respiratory depression more readily than ethanol. Peak levels occur approximately 30 minutes after ingestion because of rapid GI absorption, which is delayed in the presence of food. Isopropanol is a CNS and cardiac depressant with about twice the potency of ethanol. Serum levels more than 400 mg/dL are potentially fatal.

…Unfortunately, the conversation about consumer-driven healthcare has been largely limited to the ivory towers of government, academia, corporations and the media. Many Americans are not aware of healthcare consumerism and need to learn more about it. This was one reason why I decided to make this topic the theme of this week’s Grand Rounds. Given that some regular contributors have said they do not like themes, I was worried that my request would result in a very bare bones edition of this well-respected blog carnival. I needn’t have worried. I received more than 35 submissions for this edition and the vast majority dealt with healthcare consumerism. Following are the 25 posts I selected. Happy reading!

Happy Healthcare Consumer Reading! (Although his site seems to be down right now, probably a Kevin-lanche killed his server).

It’s a reprint of a 1993 article, and its main points are still valid, in Frontpagemag.com, by Leonard Peikoff:

Just one of the quotable quotes:

…As with any good or service that is provided by some specific group of men, if you try to make its possession by all a right, you thereby enslave the providers of the service, wreck the service, and end up depriving the very consumers you are supposed to be helping. To call “medical care” a right will merely enslave the doctors and thus destroy the quality of medical care in this country, as socialized medicine has done around the world, wherever it has been tried, including Canada (I was born in Canada and I know a bit about that system first hand).…

Recently, Gov. Schwarzenegger announced his plan to provide universal coverage for health care and declared a war on physicians. We were shocked and appalled to learn that the Governator actually wants to penalize us, clinical providers, with a 2% gross revenue tax that will hit MDs with high operating costs especially hard. His action comes at a time when we are already experiencing unprecedented levels of loss of economic liberties and an ever increasing regulation of our profession.

Even more alarming is the acceptance with which this plan, and others like it, are supported by many of our fellow physicians, politicians and the media. Supporters of universal health care–i.e. socialized medicine–would have us believe that countries like Canada and Sweden provide superior care under their government controlled system. Furthermore, they would like to shame us for being ‘the only advanced country without universal health care.’ Yet, where does the world come for its health care? America. Where did Italy’s richest politician go to have his pacemaker installed? Ohio. When confronted with examples like this, supporters of universal coverage don’t deny the quality of care America provides but argue ours is a broken system that only provides quality care for the privileged. They would have us believe that socialized systems provide an optimal level of care, available ‘for free’ to the masses, yet they refuse to acknowledge the very real, very significant problems plaguing these systems. …

I love a good rant, and that qualifies. Read it all.

Then comes the denouement, the Mark Steyn quote: however you feel about Single Payor (and it looks like the time to choose-up sides is coming) there’s a point to be had here:

…Euro-Canadian socialized health care is, in essence, subsidized by American taxpayers: since the end of World War Two, Washington has assumed the defense costs of its allies, thereby freeing up those countries to spend their tax revenues on lavish social programs. But, if America follows the Hutton plan and “joins the world,” it will reduce its defense expenditures to Euro-Canadian levels. So the next time a tsunami hits Sri-Lanka or Indonesia there will be no carrier groups to divert and save lives. So more people will die, waiting the weeks and weeks it took the sleepytime gals at the United Nations to arrive. Were America to “join the world,” it would have to reduce its funding of the UN and other wold bodies to European levels. And it might have to scale back its domestic agencies so that they’re no longer able to serve in effect as international ones. Which will be tough when some kid in some village on the other side of the world comes down with some weird illness no one’s seen before and they want to FedEx the test tube to the Centers for Disease Control in Atlanta to figure out what’s going on. Indeed, even relatively advanced societies admired by the likes of Will Hutton take it as routine that the CDC is a kind of Health Ministry of last resort. …

I am not about to say American healthcare is substandard. I will certainly agree it is fantastically expensive for those who can pay and terrifically slow for those who cannot; this is not the same as unobtainable, as there is a safety net in virtually every county in America (your county hospital). OTOH, I work in a private ED that accepts everyone without regard for insurance, status or legality and gives each the same level of care. They get admitted or discharged on their medical merits, period.

American healthcare is very American, in that it’s terrifically accommodating, has astounding abilities and also unfortunately is subject to the “I want it now and I’ll pay for it later (sucker)” mentality, and socialism in a country with no barriers to insist on More, Now scares the hell out of me.

I wanted to let you all know that the new book I’ve co-authored with Dr. Richard Jackson of Joslin Diabetes Center in Boston is now published!

It’s called Know Your Numbers, Outlive Your Diabetes – the first-ever hands-on guide to help patients identify and manage their most critical health risks with diabetes. It also guides people in setting doable action plans, giving them confidence and hope that a long and healthy life with diabetes is possible.

We’re very excited, and early reviews from doctors, educators and other patients are big thumbs-up so far.

The book is available at Amazon, Borders, Barnes & Noble, etc. As of today, you can also order a copy directly off my blog (www.diabetesmine.com) and get a free trial pack of ExtendBars (slow-release carb snack).

This week at Signout, which has been assimilated by the Science Blogs borg:

At about this time last week, I asked for bloggers’ thoughts on the interface of scientific evidence with health and health care. In an unscientific poll of the blogosphere, about 40% of you gave this theme the finger, while about 60% of you found it interesting to the point of arousal. To the first group, I say, I hope we can still be friends. Meanwhile, the second group should sit quietly and think about what it has done.

Next week’s host has clearly been keeping up with the ‘theme’ issue, and wants one, but isn’t being exclusive about it (good marketing!).

Akron doctor leads national ER group

Disaster preparedness among major issues

By Cheryl Powell

Beacon Journal medical writer

An Akron doctor who has dedicated a quarter of a century to handling local emergencies now is tackling health-care crises on a national level.

Dr. Brian F. Keaton, an emergency medicine doctor in Akron’s Summa Health System, recently started a one-year term as president of the American Academy of Emergency Physicians, a national nonprofit group.

He takes the helm at a time when issues such as emergency-room overcrowding, disaster preparedness and the growing number of uninsured are grabbing national attention.

Q: What are your responsibilities as president of the American Academy of Emergency Physicians?

Q: What tips would you give for patients for best utilizing emergency rooms?

A: The first thing you want to do is not need to come here. Preventive care, common sense and following the treatment plan that has been agreed upon by you and your primary-care physician can keep you healthier and eliminate the need for you to be here. If you find that you’re suddenly ill or injured, then we’re open 24-seven, 365. But we rather you not have to come here.

If you do come in, there are certain things you need to bring with you. Bring your list of medicines, or the bottles. Bring your list of allergies. Don’t make the assumption that I have those. Bring your list of doctors and their contact information, especially if you’re from out of town…. If you have a list of medical problems, you want to bring it with you.

When you come into the department, you need to be straightforward in terms of your complaint. We have people who come in that minimize their complaint, and they tend not to get the attention they need. We have people who come in who overplay their complaint, thinking it will get them taken care of quicker — and it may, but it makes it a lot tougher to make the diagnosis and provide the appropriate treatment.

At Movin’ Meat, Shadowfax has given a straightforward reasoning of single payor:

Before I launch into this, a couple of quick comments: First, I am not necessarily endorsing single payer as a national health plan. I do think it is probably one of, if not the, best systems possible for a nation-wide health funding system, but it does have drawbacks, as I will make clear, and is not itself a panacea. More importantly, it is a politically moribund proposal and I prefer to focus my thoughts on the possible rather than the ideal.

I encourage you to read it, as it’s very well done, even (especially) should you disagree with single payor plans.

and is reduced to using unapproved US epinephrine (oh, they’re exactly the same drug, by the way):

STOCKS of an essential drug used in life saving situations have been depleted at Middlemore Hospital.Ampoules of the Ministry of Health approved adrenalin 1:1000 ran out late last week.Middlemore is not alone in its predicament which may put patient safety at risk says the New Zealand Medical Association (NZMA). Adrenalin is an essential drug used in emergency situations such as life-threatening allergic reaction and cardiac arrest.Doctors will be able to use an alternative supply of adrenalin from America, but must gain consent from the patient, as it is not ministry approved says Counties Manukau District Health spokesperson Lauren Young.

That will be an interesting conversation:

NZdoc: ‘Hello, I see you’re about to die without our New Zealand approved adrenaline. I suppose we could give you the American version, which they call ‘epinephrine’ and does exactly the same thing, but because it’s not approved I need your permission to give it to you”.

patient: choke/gasp/wheeze

NZdoc: “I’ll record that as a yes; nurse, give the unapproved epinephrine, please”.

And, that reminds me that we have these revolving shortages of medicines you wouldn’t think of as being hard to get: injectable compazine until recently, this month it’s Bicillin LA, a long-acting penicillin shot. It’s penicillin for goodness sake, but we’re out. I never know why we have shortages like this, but they crop up all the time.

A colleague asked whether doctors were taking up with social media – i.e. starting blogs, participating in social networks/communities.

The simple answer is yes. We know this from our own research and observation as well as the good work of Dimitry of TrustedMD and Fard at Healthcare VOX. Physicians has been a traditionally non-tech savvy crowd except when you take into account generational change. Then they start to look like trailblazers. For instance, my doctor – Dr. K – old-school all the way. He barely says a full sentence to me when I am in the office and has a fleet of “girls” in the front office to operate the fax machine and other high-tech equipment. But any doctor 40 and under is walking in to the profession with PDA in hand, email-smart and even with their MySpace page up and accruing “friends” (okay, that’s for the 28-year-old doc). This is yet another case of a demographic commonly misunderstood as “not online.”

There’s a lot more, in which Kevin, MD and yr. hmbl. srvnt. are described as, I kid you not, “A-list bloggers”. It’s an interesting ‘outsider’ analysis of different types of doctor blogging.

…But Grand Themes is an entirely different kettle of fish. I blog, in theory at least, because I have things I want to say. Sometimes a subject evolves from a comment or suggestion I get, which is great: it means my blog is stimulating (or so I’d like to think.) I assume that’s what motivates most of us. To turn Grand Rounds into a theme dictated by the host is entirely different and, in my opinion, wrong. Want people to write about a subject you find interesting? Excellent idea! Post a request for submissions and call it whatever you want. Just don’t call it Grand Rounds.…

Inside Medicine: So far, electronic records don’t help patients much

By Dr. Michael Wilkes –

Not long ago, I regularly coached students and residents that during their patient encounters, they should put their papers and notes aside and listen to the person — look them in the eyes. There was so much more to be learned by having doctors use their eyes as well as their ears.

Today, a flat-screen computer sits between the doctor and the patient — just as a fence divides two neighbors. My students and residents — like doctors around the country — are slaves to the computer and electronic medical records. If you’ve not had the experience of sitting across from your doctor as she or he types your medical history into the computer, then just wait, as it is likely coming. One health-care expert calls the push for the electronic medical record (or EMR, as it is called in medical circles) the search for medicine’s holy grail….